Rheumatology - * / 1 / 2 Flashcards
Septic arthritis definition
A joint infection caused by bacteria or virus that spreads to the fluid surrounding the joint, needing immediate treatment
Common in adults and children, rare in adults unless immunosuppressed or diabetic
Common causes of septic arthritis
Staphylococcus aureus
Gonococcus: commonest in young sexually active individuals
Streptococcus
Gram negative bacilli
RF septic arthritis
Pre-existing joint disease such as RA CKD Immunosuppression Prosthetic joints IVDU
SSx of septic arthritis
Acutely inflamed tender, swollen joint, reduced ROM, systemically unwell
Ix septic arthritis
Joint aspiration for MC&S. The fluid itself will appear turbid and yellow, resembling pus.
Bloods: high WCC, high ESR/CRP, U&Es, LFTs, glucose
Blood cultures
X-ray of the joint - space widening, subluxation or dislocation, soft tissue swelling
USS - demonstrate effusion and guide aspiration
Rx of septic arthritis
IV Abx
Consider washout under GA
PT after infection resolves
Complications of septic arthritis
Osteomyelitis
Arthritis
Akylosis fusion
haematogenous vs non-haematogenous osteomyelitis
Haem - children. bacteraemia, organisms settle near metaphysis at growing end of long bone
Non - diabetic foot ulcers/pressure sores, DM, PAD. Contigous spread of infection from adjacent soft tissues to the bone or from direct injury/ trauma to the bone
SSx osteomyelitis
Localised swelling or redness of a long bone. Vertebral disease most common in adults
Fever, pain, malaise develop after a few days, limping/ refusing to weight bear Usually a child with preceding hx of trauma or infection (skin respiratory) Infants: pay present with failure to thrive, drowsiness or irritability
Ix osteomalacia
Bloods - raised WCC & neutrophils, raised ESR & CRP, blood cultures +ve in 50%, also do U&Es, LFTs, glucose
Images - plain X-ray (may be normal for ~10d), technetium-99 scan, MRI CT to define extent of bone sequestration & cavitation
Rx osteomalacia
Pain relief by bed rest, splinting and analgesia
IV ABx according to local guidelines
Surgical drainage of mature suboperiosteal abscess with debridement, obliteration of dead space, soft tissue coverage & blood supply restoration
Complications of osteomalacia
disseminated infection (septicaemia, cerebral abscess), chronic osteomyelitis, septic arthritis, deformity due to epiphyseal involvement
Causes of chronic osteomyelitis
Acute haemorrhagic osteomyelitis, contaminated trauma and open fractures, joint replacement surgery, 1o chronic infection of the bone (brodie’s abscess, TB, syphillitic osteomyelitis, myocotic osteomyelitis)
PMR definition and demographics
Inflammatory condition causing pain and stiffness in shoulders, pelvic girdle and neck.
Older adults >50, F>M, caucasian
SSx of PMR
Bilateral shoulder pain that may radiate to the elbow as well as pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning
Systemic symptoms: weight loss, fatigue, low grade fever and low mood
Upper arm tenderness
Carpel tunnel syndrome
Pitting oedema
Diagnosis and Ix of PMR
Clinical presentation and response to steroids, plus exclusion of other conditions
Bloods: FBC, U&E, LFTs, Ca, serum protein electrophoresis, CK, rheumatoid factor
Urine dip
ANA, anti-CCP, Bence Jones, CXR
Rx of PMR
Prednisolone 10-20mg/d PO - expect a dramatic response within 1week & consider an alternative diagnosis it not
Steroids for >2yrs, but decrease dose slowly
Gastric & bone protection
GCA definition
Vasculitis of the temporal artery, overlaps with PMR
SSx GCA
severe one-sided temporal headache
scalp tenderness - extreme tenderness to touch
Decreased/absent temporal pulse
Jaw claudication
Visual disturbances - amaurosis fugax (comes down like a curtain - sudden transient vision loss - posterior ciliary arteries/ central retinal artery TIA), RAPD
Polymyalgia rheumatica (30%)
Ix GCA
Temporal artery biopsy (note skip lesions can occur)
Bloods - antibodies, raised ESR/CRP, raised ALP & platelets, low Hb
Fundoscopy
Rx GCA
high dose steroids ASAP - prednisolone 60mg/d PO
(IV methylprednisolone if eye symptoms)
Typically 2yr course, the complete remission
Reduce dose once symptoms have resolved & increase again if recur
Gastric & bone protection
RF OA
obesity, age, occupation, trauma, being female and family history.
4 key X-ray changes in OA
LOSS Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
Presentation of OA
Joint pain and stiffness (commonly hips, knees, SI joints, DIPs, MCP at base of thumb, wrist, C spine)
Worsened by activity
Leads to deformity, instability and reduced function
Rx OA
Lifestyle changes - weight loss, PT, OT, orthotics
Paracetamol, topical NSAIDs + PPI, opiates, intra-articular steroid injections, joint replacement
What is crystal arthritis
Acute mono-arthropathy with severe joint inflammation caused by deposition of monosodium urate crystals
Presentation of crystal arthritis
MTP of big toe most commonly (foot, ankle, hand, wrist, elbow, knee)
Gouti tophi
Triggered by trauma, surgery, starvation, infection, diuresis, aspirin
Causes of crystal arthritis
hereditary (young males, overproducers, associated with hyper-ureic nephropathy), or secondary
Overproduction (10%): high dietary purines (protein & red meat), leukaemia, cytotoxic agents (tumour lysis), high RBC turnover (purine breakdown -> urate) e.g. tumour lysis syndrome
Under-excretion (90%): renal failure, alcohol excess, diuretics
Ix crystal arthritis
Aspirate - polarised joint microscopy shows birefringement needle shaped urate crystals
X-tray - soft tissue swelling / punched out erosions
Bloods - serum urate
Rx crystal arthritis
Rest, high fluid intake, reduce thiazides, alcohol, red meat, high dose NSAIDs, colchicine if NSAID CI’d, steroids, prevention and lifestyle modifications
Prophylaxis: allopurinol, febuxostat
Pseudogout
Calcium pyrophosphate deposition
Acute / chronic / OA with CPPD: CPP crystal arthritis, chro
RF: old age, high PTH, haemochomatosis, hypophosphataemia
Ix: +vely birefringent rhomboid shaped crystals
XR: soft tissue Ca deposition
Rx: cool packs, rest, aspiration, intra-articular steroids
Prevention: LT NSAIDs +/- colchicine may prevent acute attacks; methotrexate & hydroxychloroquine have a role in chronic CPPD
Features of RA?
systemic autoimmune inflammatory condition
Symmetrical polyarthritis (swollen, painful, stiff small joints)
Better on movement, worse in the morning
HLA DR4/DRB1 linked
Late signs of RA in the hands and extra-articular signs
Ulnar deviation (MCP), dorsal wrist subluxation, Boutonniere, swan fingers, Z deformity of thumb, foot changes, larger joints can be involved, guttering between MCPs (synovitis) Rheumatoid nodules, osteporosis, soft tissue problems (CTS, frozen shoulder), palmar erythema, lymphadenopathy, vasuclitis, amyloidosis, Raynauds, splenomegaly, pericardial effusion, CAD, episcleritis, sclerits etc in eyes.
Ix RA
Bloods: FBC (anaemia of chronic disease), U&E, LFTs, RhF, anti-CCP (gold standard), raised ESR/CRP (proportional to degree of inflammation
Imaging: X-ray (loss of joint space, osteopenia, soft tissue swelling, erosions), US (synovial hypertrophy, increased blood flow), MRI (synovitis), can aspirate joint (neutrophils)
Arthroscopy
28 joint disease activity score.
Dx of RA
Requires 4/7 Morning stiffness >3 joints affected Hand joint arthritis Symmetrical arthritis \+RF Radiological changes
Poor prognostic factors at presentation
Large number of joints involved, RF strong +ve, CCP strong +ve, smoking, early erosions, high disability score
Rx RA
Refer early to a rheumatologist (before irreversible destruction)
Early use of DMARDs (within 3 months) & biological agents
Steroids for flares (rapidly reduce symptoms & inflam - useful for treating flares) IM depot methylprednisolone 80-120mg
Intra-articular steroids have rapid but ST effects
Oral prednisolone 7.5mg/d may control difficult symptoms but SE’s
NSAIDs (good for symptom relief, no effect on disease progression)
Physio & OT (aids & splints)
Surgery (relieve pain, improve function & prevent deformity)
Replacement
Management of cardio and cerebral RF
Psoriatic arthritis
10-40% of pts with psoriasis can present before skin changes Swollen, red/soft nodules in DIP joints Nail pitting and onycholysis Asymmetrical joint involvement Sacroiliitis Anterior uveitis Synovitis X-ray: erosive changes with 'pencil-in-cup' deformity, floating syndesmophytes, DIP erosion, asymmetrical Rx: treat psoriasis - NSAIDS, sulfasalazine, methotrexate, ciclosporin, anti-TNF agents also effective
Ankylosing spondylitis
Chronic inflammatory condition affecting spine and SI joints of unknown aetiology
HLA-B27 association
SSx ankylosing spondylitis
Male <30
“young man with back pain of inflammatory nature and postural changes”. Gradual onset low back pain, worse at night (trouble sleeping), stiff in the morning (>30 mins), relieved by exercise, radiating to the hip/butt, improves at the end of the day
Spine exam: Schober’s and FABER
Features associated with ankylosing spondylitis
The As Anterior uveitis Achilles tendonitis, plantar fasciitis, costochondritis Aortic valve incompetence/ regurgitation AVN block Amyloidosis Apical pulmonary fibrosis Osteoporosis
Ix ankylosing spondylitis
MRI – most sensitive and better at detecting earlier disease
X-ray: sacroillitis, “bamboo spine” - calcified anterior longitudinal ligament, vertebrae fuse posteriorly
SPECT-CT (nuclear imaging) - see increased uptake in inflamed joints
Bloods - FBC (normocytic anaemia), raised ESR, CRP, HLA B27+ve
Rx ankylosing spondylitis
physio and exercise (not rest) for backache -> AS physio specialist
NSAIDS and PPI cover (usually relieve symptoms in 48h)
OR steroid injections for temporary relief
Anti-TNFa (infliximab, etanercept) (DMARD) if 2x NSAIDs fail (first need to check for HIV, hep B, C, TB)
Can also add Anti-IL-17 & Secukinumab
Surgery - hip replacement to improve pain & mobility, rarely spinal osteotomy
If osteoporosis consider bisphosphonates
Pathophysiology of SLE
defective apoptosis causes improper sequestration of DNA -> polyclonal B-cell secretion of pathogenic antibodies causing tissue damage via:
Immune complex formation and deposition
Complement activation
RF SLE
Autoimmune Hx, HLA-B8/DRE, high E2, drugs, Afro-Caribbean genetics
Drugs: isoniazid, hydralazine, procainamide, quinidine, chlorporazmie, phenytoin -> skin and lungs, remission if drugs stopped
SSx SLE
Relapsing and remitting
Variable presentation and course
Non-specific symptoms: fever, malaise, fatigue, myalgia
Lymphadenopathy, weight loss, alopecia, nail-fold infarcts, non-infective endocarditis, Raynaud’s, migraine, stroke, retinal exudates, episcleritis
SLE: SOAP BRAIN MD
Serositis
Oral ulcers
Artheritis (>2 peripheral joints)
Photosensitivity
Blood disorders (haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia)
Renal involvement (GN as antibody/ complement complexes in kidney -> proteinuria)
Anti-nuclear antibodies
Immunological phenomena (dsDNA, SM / antiphospholipid antibody)
Neuro (seizures, psychosis)
Malar/ butterfly rash
Discoid rash
Ix SLE
FBC (anaemia of chronic disease, autoimmune haemolysis), raised ESR (CRP normal), U&E (raised urea, creatinine)
Antibodies (ANA, anti-dsDNA)
Complement (C3/4 used up, C3b-4b high as they are breakdown products)
Urine – casts, proteinuria
Rx SLE
Severe flare - IV cyclophosphamide + high-dose prednisolone
Maintenance - NSAIDs + hydroxychloroquine + photoprotection (hydroxychloroquine causes retinopathy so regular vision checks), low dose-steroids may be of value (steroid sparing agents can be used)
2nd line: add methotrexate, azathioprine or Mycophenolate
3rd line: add biologic (Belimumab)
Cutaneous ssx - topical steroids for rashes, sun protection
Lupus nephritis - more intensive immunosuppression with steroids & cyclophospamide, BP control (ACEI), RRT
Antiphospholipid syndrome
Anti-cardiolipin antibodies, associated with SLE or as a primary disease
Definition: hypercoagulable state due to autoantibodies that increase clotting
Symptoms: CLOT:
Coagulation defects – clots (arterial and venous) -> cerebral, renal and other vessels
Livedo reticularis – rash
Obstetric complications – recurrent miscarriages
Thrombocytopenia
Rx: watch and wait (if asymptomatic)
Thrombosis - lifelong low dose aspirin or warfarin if recurrent thromboses (aim INR 2-3), seek advice in pregnancy
Recurrent miscarriage - aspirin & LMWH during pregnancy
Pathophysiology of Raynaud’s phenomenon
Peripheral digit ischemia due to intermittent spas of small arteries and arterioles of the hands and feet
Usually precipitated by cold exposure
White (ischaemia) - blue (deoxygenation) - red (reactive hyperaemia)
Causes of Raynaud’s
Primary/idiopathic Raynaud’s “disease” (almost invariably in women)
Attacks triggered by exposure to cold or stress
Bilateral arm involvement
No underlying cause or ANA; normal inflammatory markers and normal capillaries
-Secondary Raynaud’s “phenomenon” (autoimmune disease associated)
Connective tissue disorders e.g. scleroderma, polyarteritis nodosa, SLE, RA, DM/PM
Cryoglobulinemia, thrombocytosis, cold agglutinin disease, polycythaemia rubra vera, monoclonal gammopathies
Working with vibrating tools
Hypothyroidism
Thoracic outlet obstruction, Buerger’s disease, atheroma
B-blockers
Ix Raynaud’s phenomenon
anti-RNA, anti-RNP et. exclude other causes of cold, cyanosed hands e.g. pressure on subclavian artery due to cervical rib, artherosclerosis or Buerger’s disease
Rx Raynaud’s phenomenon
Conservative: wrap up warm, hand warmers, stop smoking (causes vasoconstriction)
Medical: Ca channel blockers (SE: ankle oedema), phosphodiesterase-5-inhibitors (Viagra, sildenafil - also used for pulmonary HTN)
Surgery: sympathectomy
